Provider Demographics
NPI:1922576875
Name:TATUM, SHANA S (RD)
Entity Type:Individual
Prefix:
First Name:SHANA
Middle Name:S
Last Name:TATUM
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 GARDEN OAKS BLVD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77018-5407
Mailing Address - Country:US
Mailing Address - Phone:713-252-5549
Mailing Address - Fax:
Practice Address - Street 1:104 W 12TH ST STE B
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77008-6990
Practice Address - Country:US
Practice Address - Phone:713-868-4372
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-08
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT85629133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered